Dental Health: Children

Lord Storey Excerpts

Thursday 18th January 2018 Grand Committee

[Lord Storey (LD)]

My Lords, I thank the noble Baroness, Lady Gardner, for securing this important debate. I declare an interest as a vice-president of the Local Government Association.

Many of us, though not all, will be in the fortunate position of having to clean some, if not all, of our teeth. One of the incentives to look after my teeth was the unwelcome annual inspection at school by the local authority dentist. I remember that, at the end of the day, the school secretary would come in and give out forms to every child who needed some dental attention. The parents of those unlucky enough to be given a form had two options: one, to agree to an appointment with the school dentist; two, to undertake to take the child to their own NHS dentist. In the 1950s, not sending the form back was not an option. Of course, in the 1950s, with sweets still rationed and ice cream soda a rare treat, teeth were under less threat than today.

I lived, as did many of us, in a relatively golden age of dentistry, where it was universal and free at the point of delivery. My own parents prioritised toothbrushes and toothpaste. In England today, there are many gaps in the availability of National Health Service dentists which need to be filled and, in the absence of any regular school inspections, many children and young people are unaware of the state of their teeth until toothache demands the attention of a dentist.

Of course, many parents ensure that their children take care of their teeth through regular brushing and taking care with their diet. They make sure that, for example, their children’s teeth are not regularly submerged in fizzy drinks or coated with chocolate. However, the rise in the need for very young children to have all or some of their milk teeth extracted has a range of very heavy costs, both in human and financial terms.

Many Members will recall when Margaret Thatcher removed free school milk in 1971, earning, sadly, the title “Milk Snatcher”. This policy was eventually reversed and, today, every child under five is entitled to free milk. When we had a similar debate last year, the then Education Minister, the noble Lord, Lord Nash, said that he would look into whether we could provide free school milk for all primary school children, and there was a large article in the Telegraph. Could the Minister tell us where we are up to with the thoughts of the noble Lord, Lord Nash, on free school milk for every primary school child?

The area I live in, the north-west, has some of the highest rates of tooth decay. About 15 years ago, my local authority decided to introduce what is called dental milk, where a medically correct amount of fluoride is put in the milk. Parents had the choice of their child having a carton of dental milk or a carton of ordinary milk. The parents of 99% of the children in my school chose the dental milk. I think 10 local authorities introduced it. When replying, could the Minister tell us whether any evaluation has been undertaken of the dental milk project and where we are up to on its development? I listened to the noble Baroness, Lady Gardner, talk about fluoride in the water supply, and this might be another initiative that we might look at to help prevent dental decay in our children.

It is difficult to imagine how awful it must be for a two year-old to suffer the trauma of hospital admission, general anaesthesia and the extraction of their teeth. The parents will also pay a heavy emotional price as they support their child before, during and after the procedure. In financial terms, the cost of what is a major operation is considerable, and inevitably takes scarce resources away from surgery that is less avoidable.

We all know how difficult it is for adults to get on the list for an NHS dentist in some areas, and how many adults end up paying for regular check-ups, or paying the price for not having them. What we do know is that many parents do not seem to be aware that dental care, as my noble friend Lady Benjamin said, is free for children and that although 60% of practices accept children, 40% do not—40%.

We are always asking today how we can reduce pressures on the NHS. Tooth decay is the leading reason for hospital admissions of young children and the most preventable. Dealing with this issue would help to relieve those pressures on the NHS. I hope that as a result of this really important debate, the Government might come forward with some new initiatives which will deal once and for all with the problem of young children and teeth.

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[Baroness Chisholm of Owlpen (Con)]

I apologise at the beginning for the fact that I will have to speak quite fast because I do not have very long and have quite a lot to say. I do not want people to think that I am galloping through it because I am not interested in what I am saying—I am.

I congratulate my noble friend on securing time for this important debate today, and I am pleased to have the opportunity to talk about what the Government will do in this area. We all recognise that poor oral health for children can have a devastating impact on a child’s quality of life.

We need to keep in mind that, overall, children’s oral health is better than it has ever been, with the most recent data from 2015 showing that 75% of five year-old children in England are now decay free. Between 2008 and 2012, the number of five year-old children who showed signs of decay fell by approximately 10%. This is fantastic progress, but it still leaves 25% of five year-old children experiencing decay, which is unacceptable. As was said by my noble friends Lord Colwyn and Lady Gardner of Parkes and the noble Baroness, Lady Thornton, one child needing to have tooth extractions under general anaesthetic due to poor oral health is one child too many. This is why improving children’s oral health is a priority for this Government. The noble Baroness, Lady Thornton, said that the Government do not feel dentistry to be important. However, our manifesto made clear our commitment to support NHS dentistry, improve coverage and achieve better outcomes, especially for deprived children.

The key issue now for child oral health is that of inequality, as the noble Baroness, Lady Thornton, mentioned. Active dental disease is now clustered in deprived groups and areas. Dentists can and do play an important role in improving oral health, but patients understanding the wider issues involved—from diet and good oral hygiene to the role that fluoride can play—is crucial to progress.

The good news is that a good diet and good oral hygiene, together with regular visits to the dentist and access to clinically proven prevention measures such as fluoride, go a long way to eliminating dental disease. The bad news is that, as we all know, the issues surrounding children’s poor oral health are complex, and this means that there is no easy or quick fix for those currently left behind.

Dentists have a vital role to play in providing regular check-ups for children, giving important messages to parents about self-care at home and providing evidence-based interventions, such as fluoride varnish applications, alongside any necessary treatment. Delivering Better Oral Health, Public Health England’s key guidance to dentists, is clear on the need for regular applications of fluoride varnish for all children at recommended intervals. I am delighted that, in 2016-17, 4.7 million children had courses of treatment for fluoride varnish applications, a 13.9% increase on the previous year. Fluoride varnish applications now equate to 41.2% of all child treatments, making them the most common dental treatment for children.

Every noble Lord who spoke today talked about fluoridation in the water. The clinical case for fluoride’s effect on oral health and the benefits of water fluoridation is substantial. The Government and Public Health England would warmly welcome a decision by a local area to fluoridate the water supply. However, such decisions must be made locally. Local authorities were given responsibility for water fluoridation in the Health and Social Care Act 2012. Given the level of debate that water fluoridation has historically aroused, unlike fluoride toothpaste or varnish, it is important that there is clear local ownership of decisions. However, the case continues to be made by Public Health England that we want as many local areas as possible to make sure that it happens. Water fluoridation benefits the overall oral health of the population. NHS England already bears the cost of delivering fluoride where this is done through a dental intervention such as applying fluoride to teeth, and there are no plans for the costs of water fluoridation to be met centrally.

Turning to the issue of access to a dentist, NHS England commissions primary dental services and has a duty to commission services to meet local need. In the 12-month period ending 30 September 2017, 6.8 million children were seen. This equates to 58.8% of the child population. We appreciate that some areas have access difficulties, even for children. I know that NHS England is committed to improving the commissioning of primary care dentistry within the overall vision of the five-year forward view.

I want to mention some of the specific actions being taken to improve access and the care that dentists can give patients once seen. We are committed to introducing a new NHS dental contract, which will improve the oral health of the population and further increase access to NHS dentistry. Seventy-five high-street practices continue to test a prevention-focused clinical pathway, which includes offering all patients an oral health assessment and advice on diet and good oral hygiene. Follow-up appointments are offered where necessary to support patients’ self-care and carry out any necessary preventive treatments.

The new approach aims to increase patient access by paying dentists for the number of patients cared for, not just for the treatment delivered, as per the current contract. It is important to be clear that the scheme will have to demonstrate that it can maintain access and improve oral health, including that of children, in a way that is sustainable for practices, patients and NHS commissioners before any decision will be taken on a wider national rollout.

My noble friend Lady Gardner of Parkes talked about children not attending dentists, and my noble friend Lord Colwyn, the noble Baroness, Lady Benjamin, and many others mentioned the Scottish initiative. However, I would like to talk about the wider reform of the current approach. NHS England is developing schemes focused specifically on children in areas of high dental need.

As it has already been mentioned in the debate, I am sure that many here are familiar with the Starting Well programme. Noble Lords seem to feel that it will not be sufficient, but it is aiming to improve oral health outcomes for young children in deprived areas. The programme will work in 13 high-priority areas, with the aim of increasing the provision of evidence-based advice and interventions for all children under the age of five, but especially for those who do not regularly visit a dentist. This will, where appropriate, include outreach to children not currently in touch with dental practices.

Alongside that, NHS England is also developing a complementary Starting Well core offer. This is a commissioning approach designed to facilitate increased access and early preventive care for young children anywhere in the country where local commissioners decide it is needed. I understand that this offer will be made available to commissioners by NHS England later this year. It will bring to a wider audience the key message that I know the Chief Dental Officer passionately champions—the importance of starting oral health care and dental attendance as young as possible.

Ensuring access to dental services and treatment is the responsibility of NHS England. However, it is important also to talk about the role of Public Health England in improving children’s oral health more generally. This area of public health is very much a priority for Public Health England. The noble Baroness, Lady Grey-Thompson, talked about a joined-up approach to dentistry and other areas, and the noble Baroness, Lady Benjamin, talked about the LGA implementing Public Health England’s recommendations. Public Health England has established the Children’s Oral Health Improvement Programme Board, which brings together a wide range of stakeholders and has an extensive work programme. Public Health England, through the board, co-ordinates all the work being taken forward across the system on improving child oral health. One of the outputs has been the updating of the “red book” to ensure that all new parents receive clear messages about the importance of good oral hygiene and early dental attendance.

Many noble Lords have spoken about sugar. Prevention is a key part of the work that Public Health England leads. Diet is very important—particularly sugar intake, which is the leading cause of dental decay. The sugar levy and the sugar reformulation programme are therefore very important in improving oral health, as well as having an impact on the wider issues of obesity.

Following on from that, the noble Baroness, Lady Grey-Thompson, mentioned energy drinks and the problems that athletes have had. As we know, energy drinks can be high in caffeine and sugar. Alongside our measures to reduce sugar, we will continue to monitor the situation and look at any emerging scientific evidence on the consumption of energy drinks. I hear what the noble Baroness says. As I said, we will monitor this. Since we published the plan on the sugar levy, there has been real progress. The levy has become law and will come into effect in April 2018. Public Health England has formulated a comprehensive sugar reduction programme with the aim of a 20% reduction in sugar in key foods.

My noble friend Lady Redfern talked about what schools can do. We expect all schools to have healthy eating policies. The noble Lord, Lord Storey, talked about milk in schools. Although nutrients in milk are useful for healthy teeth, milk does not per se improve teeth, and calcium, which is needed for healthy growth in teeth and bones, can be found in a number of foods. However, poor diet is a key risk factor of poor dental health, and all children are encouraged to reduce their intake of free sugars. Milk is a safe alternative to sugar and sweetened drinks, is safe for children’s teeth and is recommended for delivering better oral health in the evidence-based toolkit for prevention.

[Lord Storey]

If the Minister does not have the information about dental milk, could she write to me about it?